Family will never know how dad died after HSE blunder
Published 14/12/2010 | 05:00
A GRIEVING family will never know why their father died because Health Service Executive (HSE) staff failed to notify the coroner of his death for two weeks, a damning report has claimed.
Ombudsman Emily O'Reilly yesterday said "carelessness" had led to staff at the Mid- Western Regional Hospital in Limerick breaking their own guidelines to alert the coroner to the death.
And she said by the time the coroner was finally informed he could not conduct a post-mortem examination -- which would confirm the cause of death -- as the man had been buried.
The 61-year-old man had been admitted to the hospital's high dependency ward in November 2005 suffering from a stroke.
However, he fell out of bed -- suffering a broken tooth, an 8cm laceration to the back of his head and cuts to his tongue -- and died 52 hours later.
The coroner conducted an inquest into the death, but returned an open verdict as he could not definitively say if the man died from a stroke or from the fall without a post-mortem result.
"The hospital failed to carry out a post-mortem in line with hospital policy or to advise the family in this regard," Ms O'Reilly said.
"The hospital failed to advise the coroner of the patient's death in a timely fashion. I find that these actions have adversely affected the family and the actions were, or may have been, the result of carelessness," she added.
"I believe that it is reasonable for the family to have doubts about the HSE's contention that his death was caused purely by his stroke and not contributed to by the bad fall he suffered whilst in hospital."
Ms O'Reilly said the patient had died at the weekend when his admitting consultant and team were on leave. He was considered to be dying on the Friday, but his team had not discussed the possible requirement for a post-mortem should he die.
As a result, a junior on-call doctor was asked to certify his death and did not query if it had been related to the fall.
The failure was just one of many highlighted by Ms O'Reilly in the highly critical report.
She said the man's remains were left on the ward for almost six hours after his death. She insisted it was inappropriate and insensitive that the patient's soiled pyjamas were left in his bedside locker for three days, only to be found there by the family after he died.
And she was critical of the fact that there was no evidence that staff had undertaken a falls risk assessment of the patient.
"The patient and his family were not afforded the basic standard of dignity or privacy in the final moments of his life, or in the hours the remains were left on the ward subsequently," she said.
"I find that these failures were the result of negligence or carelessness."
Last night the HSE apologised for the failure of a number of staff to adhere to hospital policy and advise the coroner of the death of the patient in a timely fashion.
"This delay was not intentional and the adverse effect on the family was deeply regretted," said a spokesman.
But he insisted that improvements had been made and that a member of the hospital's senior management team was planning to visit the family to apologise in person for the failures.